Form A5625 - Illinois Statutory Short Power Of Attorney For Health Care Page 5
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5ILLINOIS STATUTORY
SHORT FORM POWER OF ATTORNEY
FOR HEALTH CARE
7. I am fully informed as to all the contents of this form and understand the full import of this grant of
powers to my agent.
Dated: __________________
Signed _____________________________________________________
(principal’s signature or mark principal)
The principal has had an opportunity to review the above form and has signed the form or acknowledged his
or her signature or mark on the form in my presence. The undersigned witness certifies that the witness is
not: (a) the attending physician or mental health service provider or a relative of the physician or provider;
(b) an owner, operator, or relative of an owner or operator of a health care facility in which the principal is a
patient or resident; (c) a parent, sibling, descendant, or any spouse of such parent, sibling, or descendant of
either the principal or any agent or successor agent under the foregoing power of attorney, whether such
relationship is by blood, marriage, or adoption; or (d) an agent or successor agent under the foregoing power
of attorney.
___________________________________________ ___________________________________________
(witness signature)
(print witness name)
_______________________________________________________________________________________
(street address)
_______________________________________________________________________________________
(city, state, ZIP)
(NOTE: You may, but are not required to, request your agent and successor agents to provide specimen
signatures below. If you include specimen signatures in this power of attorney, you must complete the
certification opposite the signatures of the agents.)
I certify that the signatures of my agent (and successors) are correct
____________________________________________________________
(agent) (principal)
____________________________________________________________
(successor agent) (principal)
____________________________________________________________
(successor agent) (principal)
(NOTE: The name, address and phone number of the person preparing this form or who assisted the principal
in completing this form is optional.)
____________________________________________________________
(name of preparer)
____________________________________________________________
____________________________________________________________
(address)
____________________________________________________________
(phone)
A5625
Rev. 09/01/2011
800 E. Carpenter Street · Springfield, Illinois 62769
Page 5 of 5
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